Evaluation of the effectiveness of training in basic and assisted communication techniques for intensive care nurses

Abstract

Introduction

Specialised training in communication techniques is necessary for intensive care nurses to communicate effectively with critical care patients.

Objective

To evaluate the effectiveness and satisfaction of a training programme in basic communication skills (BCS) and augmentative and alternative communication (AAC).

Methods

A two-phase mixed-methods design was used: phase I was cross-sectional descriptive, and phase II was quasi-experimental. A total of 120 nurses working in the intensive care units of Vall d’Hebron Hospital were recruited for phase I, of whom 30 were included in phase II. The intervention consisted of a training programme in BCS and AAC, accredited by the University of Barcelona and comprising four modules, lasting six hours. Participants’ perception of their communication skills was assessed, as well as evaluation of the knowledge acquired through a written test and nurses’ satisfaction with the programme through an ad hoc questionnaire.

Results

Regarding BCS, 71.4% (n = 86) of participants had received training and 78.3% (n = 94) stated they used them. Regarding AAC knowledge, 88.3% (n = 106) reported lack of familiarity with these techniques. Nurses who received training demonstrated significant improvements in their perception of verbal communication use (MD −0.46; p < 0.001), non-verbal communication (MD −1.20; p < 0.001), AAC knowledge (MD −1.96; p < 0.001) and importance of effective communication (MD −0.16; p = 0.02). The post-test knowledge level obtained an average score (>3 out of 4). 83% (n = 25) of nurses were very satisfied with the training and 18% (n = 5) were satisfied.

Conclusion

Training in HCB and AAC led to significant improvement in ICU nurses’ knowledge regarding communication with critically ill patients experiencing communication difficulties. Furthermore, the training was positively received by nurses.

Resumen

Introducción

Es necesario que las enfermeras de cuidados intensivos reciban formación especializada en técnicas de comunicación para poder comunicarse de manera eficaz con los pacientes en estado crítico.

Objetivo

Evaluar la efectividad y satisfacción de un programa de formación en habilidades de comunicación básica (HCB) y comunicación aumentativa y alternativa (CAA).

Métodos

Se utilizó un diseño mixto en dos fases: la Fase I fue observacional descriptiva transversal, y la Fase II cuasi-experimental. Se reclutaron 120 enfermeras de las unidades de cuidados intensivos del Hospital Vall d’Hebron para la Fase I, de las cuales 30 participaron en la Fase II. La intervención consistió en un programa acreditado por la Universidad de Barcelona, con cuatro módulos y una duración total de seis horas. Se evaluó la percepción de las participantes sobre sus habilidades comunicativas, el conocimiento adquirido mediante una prueba escrita y la satisfacción con el programa a través de un cuestionario ad hoc.

Resultados

El 71,4% (n = 86) había recibido formación en HCB y el 78,3% (n = 94) afirmó utilizarlas. El 88,3% (n = 106) indicó no estar familiarizado con la CAA. Las enfermeras que recibieron formación mostraron mejoras significativas en la percepción del uso de la comunicación verbal (MD -0,46; p < 0,001), no verbal (MD -1,20; p < 0,001), conocimiento de la CAA (MD -1,96; p < 0,001) y la importancia de la comunicación efectiva (MD -0,16; p = 0,02). El nivel de conocimiento post-test obtuvo una puntuación media superior a 3 sobre 4. El 83% (n = 25) se mostraron muy satisfechas con la formación y el 18% (n = 5) satisfechas.

Conclusión

La formación en HCB y CAA mejoró significativamente el conocimiento de las enfermeras de UCI sobre la comunicación con pacientes críticos con dificultades comunicativas, y fue bien valorada por las participantes.

What is known

Effective communication is essential in critical care nursing. The employment of augmentative-assistive communication interventions has been demonstrated to enhance the psycho-emotional effects on critical ill patients. This underscores the necessity for specialised training in communication techniques for nurses.

What it contributes

The study provides nurses’ perceptions of effective communication with critically ill patients based on basic and augmentative-assisted communication techniques, as well as an assessment of nurses’ knowledge of basic and augmentative-assisted communication after formal training.

Implications of the study

A comprehensive understanding of nurses’ perceptions regarding effective communication is imperative to facilitate the exploration of an appropriate training approach. Furthermore, the proposed communication programme supplies nurses with the requisite tools and resources to communicate with patients experiencing communication difficulties in a clinical context.

Background

The interaction between nurses and patients is crucial to providing care for individuals in critical health conditons.^1,2 The vulnerability and fragility experienced by these patients increases when communication with health personnel is not effective.^3–6 The difficulties presented by critical patients in expressing themselves often generate loneliness and lack of communication^7,8 and have an impact on the quality of nursing care.^9–11 Additionally, nursing professionals feel frustrated when they are unable to communicate effectively with these patients.^12,13

In this context, several authors have investigated the use of basic communication skills (BCS) such as empathy, active listening, eye contact, and message confirmation¹³ and the implementation of augmentative and alternative communication (AAC) techniques at different levels of technology (gestures, whiteboards, or digital devices) in intensive care units (ICUs).^5,14 This evidence shows that training in BCS and AAC and their use in clinical practice improves nurse–patient communication and has an impact on the health status of the critically ill patient.¹⁵ However, there are different personal, structural, and planning barriers that hinder their applicability in clinical practice, such as the lack of formal training, the workload of nurses, and lack of time.^16,17

The COVID-19 pandemic declared by the World Health Organisation in March 2020 generated a change in the structures and organisation of the health system.¹⁸ The rapid spread of the virus and the increase in deaths destabilised health centres, forcing them to adapt with respect to material, structural and human resources.¹⁹ One of the most affected sectors in this context has been intensive care services, whose professionals have had to make a great effort to adapt to this exceptional and serious situation.²⁰ In this sense, new communication barriers were added, such as isolation and the use of personal protective equipment, which highlighted the importance of interactions between nurses and critical patients.^21,222 This phenomenon led to an increase in the sensitivity and interest of these professionals in communicating effectively across these barriers.²¹

Recent studies show that nurses suffered anxiety, stress, and fatigue in the process of adapting to the new situation and that adequate specialised training in communication techniques would help nurses’ professional development and consequently improve nursing care for critically ill patients.^17,18,20,22 Sharour et al. (2021) suggest that better-trained and more experienced nurses communicate more effectively. However, recent studies also show that these professionals do not have sufficient knowledge of AAC techniques and/or their application and, therefore, more formal training in this type of techniques is needed.^23,24 Prats (2017) created a training model in BCS and AAC for intensive care nurses (CONECTEM).²⁵ This model, validated by a group of experts, was based on three communication strategies according to the Glasgow coma scale and the sensory, motor, and cognitive limitations of the patient. Each strategy included actions based on social skills, communication skills,²⁶ guidelines for effective communication²⁷ with BCS, and low-tech AAC tools.²⁸ This pilot study improved communication between nurses and patients by assessing the latter's needs and reducing the psycho-emotional effects of critical illness.¹

For this reason, the main objective of this study to evaluate the effectiveness of a training programme in basic and assisted communication techniques (i.e., CONECTEM) in relation to the level of knowledge and degree of satisfaction of ICU nurses.

Methods

Design

The study design was structured in two phases. A cross-sectional, descriptive, observational design was used in phase I, and a quasi-experimental pre–post design of a single group with a sub-sample to assess the changes after training was carried out in phase II. The study was conducted at one of the largest public hospitals in Catalonia, Spain between 2020 and 2022. This tertiary care hospital, located in the city of Barcelona, is part of the European University Hospital Alliance. The facility is equipped with five intensive care units, one designated for paediatric patients and four for adult patients, offering a total of 128 beds.

Participants and sample

The study sample comprised nurses working in the four adult intensive care units (ICUs) at Vall d’ Hebron Hospital in Barcelona. The inclusion criteria were: One year minimum of ICU experience and working at least 16 hours per week. The exclusion criterion was any severe vision or hearing problem.

In phase I, the sample was selected using the snowball technique. Of the 155 nurses who met the inclusion criteria, 35 refused to participate. The final sample therefore consisted of 120 ICU nurses. In phase II, consecutive cases were selected using convenience sampling. Thirty ICU nurses were selected in this phase.

Variables and instruments

Sociodemographic variables (sex, age, work shift, level of education completed, professional experience, and previous training received in BCS) were collected in an ad hoc questionnaire.

The variables on the perception of knowledge in relation to BCS and AAC for critical patients (knowledge and application of BCS; knowledge and application of AAC; use of verbal and non-verbal communication; frequency and duration of nurse-critical patient interactions; perception of the influence of communication on the evolution of critical patients; degree of frustration when communication is not effective), were collected through an ad hoc questionnaire containing 13 items. Ten items were measured with a Likert scale from 1 to 4 [1 (not at all) and 4 (A lot)], two items with a stratified response, one in terms of frequency of communication/day (none, between 1 and 3, 3–5, more than 5) and the second in terms of duration of nurse–patient interaction in minutes (less than 1, 1 min, 3–5 min, 5 or more and one with a short response.

The participants’ level of knowledge about BCS and AAC was assessed using a written test developed by a group of experts. The test consisted of three clinical cases of critically ill patients with various communication difficulties, as determined by their Glasgow Coma Scale score. Each case had four short-answer questions, in which nurses had to identify the correct communication strategy, detect the patient's needs, indicate which BCS and/or AAC techniques they would use, and define the elements necessary to establish effective communication. Nurses were considered to have a low level of knowledge if they answered 2 or fewer questions (50%) correctly in at least two of the cases; an intermediate level if they answered 3 or more questions (75%) correctly in at least two of the cases; and a high level if they answered 3 or more questions (75–100%) correctly in all three cases

Finally, perceived satisfaction after training was evaluated by means of an ad hoc questionnaire with eight items, based on a Likert scale from 1 to 5 [1-very poor, 2-poor, 3-suficient, 4-good, 5-very good)]. The following were assessed: (1) the material and methods used, (2) the usefulness of the information provided, (3) the teacher's organisation in the structuring of course activities, (4) the clarity of the explanations and importance of the content, (5) the encouragement of student participation, (6) the satisfactoriness of responses to the students’ questions, (7) the evaluation system used, (8) overall assessment of the course.

Training programme

The training programme in BCS and AAC techniques called CONECTEM, is a programme validated by a group of experts in the field and accredited by the University of Barcelona. The syllabus is composed of four theoretical blocks: (1) Anthropology and the theoretical bases of communication applied to nursing, (2) The critical patient and psycho-emotional effects, (3) CONECTEM communicative intervention, (4) Programme structure and evaluation, and three practical workshops: (a) Psycho-emotional effects and emotion management, (b) Application of the CONECTEM communicative model, and (c) Music therapy, where the different knowledge, communication skills, and attitudes related to BCS and AAC applied to the critically ill patient are presented. The method used includes work through discussion groups, role-playing techniques, and case resolution. The training lasted 6 hours. This training programme is published in the Digital Deposit of the University of Barcelona.²⁹ Preliminary results of this programme have been presented in previous publications.¹ The details of the training are set out in Table 1.

Table 1.

Training programme.

BLOCK 1	Anthropology and theoretical bases of communication applied to nursingBasic concepts
Basics	– Anthropological view of communication– Communicative paradigms • Verbal communication (language, paralinguistics, intentionality) • Non-verbal communication (corporeality, touch, gaze, smile)– Effective communication (models and theories) • “Theory helping human relationships” (Carkhuff 1968)^1 - Initial dimension/Response dimension - Reflective process with the patient - Social and communication skills • “Augmentative assistive communication” (Beukelman, Garret, & Yorkston, 2007)^2 - Model for patients with communication difficulties - Communicative dimensions (social circle, wants and needs, routine, and information) - Technology levels
Objectives	– Recognise the importance of communication in the human condition– Recognise the different communicative paradigms and how they relate to each other.– Integrate the reflective communicative process into clinical practice– Know the scope of the different assisted communication strategies
Practical exercises	– Integration of verbal/non-verbal communication • Blind man's bluff • Wax figures • The encrypted message

BLOCK 2	Psycho-emotional aspects of the critically ill patient
Basics	– Description and characteristics of the critically ill patient (loneliness, vulnerability, frailty, lack of communication)– Psycho-emotional effects • Pain • Anxiety • Symptoms of post-traumatic stress
Objectives	– Understand the context of the critical illness and what it means for the person– Identify the importance of psycho-emotional effects for the recovery and prognosis of the critically ill patient– Distinguish the most prominent psycho-emotional effects on the critically ill patient– Identify the characteristics of the psycho-emotional effects (pain, anxiety, and post-traumatic stress)
Practical exercises	– Emotions workshop to address pain, anxiety, and post-traumatic stress

BLOCK 3	CONECTEM communicative intervention
Basics	Explanation of how to apply the intervention in the ambulanceIntervention: three communication strategies according to the patient's Glasgow score– Strategy 1 (Glasgow 15) • Make eye contact • Confirm messages • Use pauses • Ask clear, concrete questions • Show empathy, mutual respect, and assertiveness– Strategy 2 (Glasgow 14-9) • Use concrete and precise language • Use short sentences • Establish signs for yes, no, and I don’t understand • Use AAC with a whiteboard and pictograms of emotions and needs– Strategy 3 (Glasgow <9) • Observe facial expressions and bodily movements • Watch for changes in vital signs • Offer a quiet environment (avoid excess light, noise etc.) • Make physical contact • Play musicScales and Instruments: – Pain (VAS, BPS) – Anxiety (STAI, Ramsay Scale) – PSD (IES, Richmon Scale)
Objectives	– Understand the concepts explained in the CONECTEM communication intervention and put them into practice– Strengthen the actions to carry out each communicative strategy– Apply each communicative strategy according to the needs of each patient
Practical exercises	– Case management– Role-playing– Music therapy workshop

BLOCK 4	Sessions of the CONECTEM programme
Training planning	– Distribution of the contents and session schedule (two 2-hour sessions)– Materials used– Session timing
CONECTEM PROGRAMME METHOD
PowerPoint, case studies, small group work, role-playing, video
CONECTEM PROGRAM EVALUATION
Theoretical–practical exam of three cases containing four questions eachPass: Answer correctly 70% of each case

Note: AVS: Analog Visual Scale; BPS: Behaviour Pain Scale; STAI: State-Trait Anxiety Scale; IES: Impact Event Scale.

Used with permission from Prats Arimon, M. et al., 2022. Training programme based on BCS and AAC for out-of-hospital nurses. Enfermería Global. 21, 3 (Jul. 2022), 109–134. DOI: https://doi.org/10.6018/eglobal.507341

Procedure

In phase I of the study, two members of the research team who worked at the hospital where the study was conducted were responsible for distributing and collecting the questionnaires and entering the data into a database. The questionnaires were administered to participants during their working hours over a 21-day period. In phase II, a total of thirty nurses who had participated in the baseline of the initial phase underwent communication training based on BCS and AAC. The training was led by the principal investigator of the CONECTEM project, following the guidelines that had been approved by the group of experts who had designed the training. The theoretical component of the programme was delivered during the initial 2.5 hours of the training session, while the three practical workshops were facilitated with the assistance of two other members of the research team during the subsequent 3 hours. The level of knowledge was ultimately assessed on an individual basis via a written test. Moreover, the pre-test questionnaire on the perception of communication knowledge was re-administered in order to measure changes, and the training satisfaction questionnaire was also administered.

Ethical aspects

This study was approved by the Ethics Committee of the Vall D’Hebron University Hospital with reference PR(AG)120/2019. The study was based on the Helsinki Declaration on the Ethical Principles of Medical Research involving human participants. All nurses who completed the training signed an informed consent form and were afforded confidentiality.

Data analysis

For the descriptive analysis of the cross-sectional study, absolute and relative frequencies were calculated as a percentage for the qualitative variables. For the analysis of the quantitative ones, the mean and standard deviation were calculated when they followed a normal distribution, and the median and interquartile range when they did not.

For the quasi-experimental study, the normality of the quantitative variables was assessed using the Shapiro–Wilk test (p > 0.05 indicating a normal distribution). The data showed a normal distribution; therefore, Student's t-test was applied for group comparisons. Categorical variables were analysed using Pearson's chi-square test. The threshold for statistical significance was set at a p-value of 0.05. The effect size was estimated using Cohen's coefficient d, considering a moderate effect to be |d| ≥ 0.5 and large effect to be |d| ≥ 0.8. Data analysis was performed with the SPSS v.27 statistical package (LEAD Technologies, Chicago, Illinois).

Results

Of the 155 nurses who met the inclusion criteria, 35 declined to participate in the study. Consequently, 120 nurses were included in phase I, while 30 nurses were included and allocated in phase II. See Fig. 1.

Figure 1.

Flow diagram of study participants.

Sociodemographic characteristics of the sample

The mean age of the participants was (38.36 ± 0.95 years). Eighty per cent of the sample (n = 96) were women, and 62.5% (n = 75) worked the day shift. 48.3% of the participants (n = 58) had a master's degree, and 65.8 (n = 79) had more than 10 years of professional experience. Regarding previous training in BCS, 71.4% (n = 86) of respondents reported receiving training during their bachelor's or master's degree. The variables are described in Table 2.

Table 2.

Sociodemographic data for the sample.

	Total(n = 120)
	n	%
Gender
Female	96	80.0
Male	24	20.0
Maximum level of studies
Bachelor's degree	62	51.7
Master's degree	58	48.3
Work shift
Day	75	62.5
Night	45	37.5
Working experience
<5 years	19	15.8
Between 5 and 10	22	18.8
>10 years	79	65.8
Previous BCS training
Yes	86	71.4
Bachelor's-level	58	48.3
Master's-level	28	23.3
No	34	28.3

	Mean	SD
Age (years)	38.36	0.95

Note: SD: standard deviation; BCS: basic communication skills.

Perception of knowledge in BCS and AAC

Table 3 shows the perception of knowledge that ICU nurses reported about effective communication with critical patients. Approximately 57.5 (n = 68) having none or a little prior training in BCS, although 78.3% (n = 94) reported applying BCS during their clinical practice. In contrast, 88.3% (n = 106) were not aware of AAC and did not use it in their day-to-day work with patients. Only 11.6% (n = 14) of the nurses used AAC strategies without digital technology; the most commonly used of these were writing with a percentage of 21.7% (n = 26) and gestures with a percentage of 13.3% (n = 16). In reference to patients on mechanical ventilation, 85% (n = 102) of the nurses reported verbal communication with patients. Regarding nonverbal communication, the results show that 72.5% (n = 87) of the nurses also used nonverbal communication with patients on mechanical ventilation, although to a lesser extent than verbal communication. In relation to the frequency, the results indicate that 87.5% (n = 105) of the nurses communicated with the patient more than five times per 12-hour shift. However, in terms of the duration of each interaction, 53.3% (n = 64) of the nurses spent only between 3 and 5 minutes. 78.3% (n = 94) of the nurses reported that their communication with the critical patient was usually effective, although 80% (n = 96) reported feeling frustrated when it was not. 92.5% (n = 111) of the nurses agreed on the need for communicative resources for effective communication with the critical patient and thought that effective communication was an important influence on patients’ health status. See Table 3.

Table 3.

Pre-test perception of knowledge about communication techniques.

	Total(n = 120)
	n	%
Nurses’ BCS knowledge
None	2	1.7
A little	67	55.8
Pretty much	48	40
A lot	3	2.5
Incorporates BCS into practice
Not at all	1	0.8
A little	25	20.8
Pretty much	67	55.8
A lot	27	22.5
Verbal communication with OTI patients
None	1	0.8
A little	17	14.2
Pretty much	65	54.2
A lot	37	30.8
Nonverbal communication with OTI patients
None	8	6.7
A little	25	20.8
Pretty much	54	45
A lot	33	27.5
Frequency of interaction
1–3 times per shift	1	0.8
3–5 times per shift	14	11.7
>5 times per shift	105	87.5
Duration of interaction
<1 min	3	2.5
1–3 min	17	14.2
3–5 min	64	53.3
>5 min	36	30.0
Knowledge of AAC
None	55	45.8%
A little	51	42.5%
Pretty much	13	10.8%
A lot	1	0.8%
AAC techniques used
Lip reading	8	6.7
Writing	26	21.7
Signs	16	13.3
Doesn’t know/doesn’t answer	70	58.3
Frustration in ineffective communication
A little	24	20
Pretty much	57	47.5
A lot	39	32.5
Need for communication resources
A little	9	7.5
Pretty much	38	31.7
A lot	73	60.8
Importance of communication for health status
A little	2	1.7
Pretty much	33	27.5
A lot	85	70.8
Perception of effective communication
Pretty much	26	21.7
A lot	94	78.3

Note: BCS: basic communication skills; OTI: orotracheal intubation; AAC: augmentative and alternative communication.

Quasi-experimental study: comparison of perception of knowledge about communication pre- and post-CONECTEM training

The sociodemographic characteristics of the sub-sample of 30 participants who received the training were as follows: 83.3% (n = 25) were women, the mean age was (37.8 ± 8.10 years), 83.3% (n = 25) worked the day shift, 70% (n = 21) had more than 10 years of experience, and 46.6% (n = 14) had completed a master's degree. As for previous training in BCS, 70% (n = 21) had taken a training course during their professional career.

Table 4 shows that, after the CONECTEM training, most variables related to knowledge about BCS and AAC improved significantly. The nurses who completed the CONECTEM training improved their perception of the importance of effective communication with the critically ill patient (p = 0.02), increased their knowledge of AAC (p < 0.001), and reported that they intended to apply in clinical practice the BCS described in the training (p < 0.001) and those they already knew previously according to the proposed communicative model. On the pre-training test, we found that 80% (n = 24) of the nurses did not know about or use any AAC technique, while 20% (n = 6) used AAC techniques without digital technology such as writing or lip reading. In contrast, on the post-test, 43% (n = 13) stated that they would use low-tech techniques (signs depicting emotions or needs) and high-tech (patient app tablet) AAC in communication with the critical patient, 27.6% (n = 8) said that they would use low-tech AAC, and 30% (n = 9) that they would use low-tech AAC and non-technological AAC. The only variable that was not statistically significant in the post-test was the need for communication resources (p = 0.09), since in both the pre- and post-tests most nurses believed it was very necessary to have resources to communicate with the critical patient. See Table 4.

Table 4.

Pre–post training differences in nurses’ perception of knowledge about communication.

	Pre-test		Post-test
	Mean	(SD)	Mean	(SD)	MD	p-Value	|d|
Verbal communication with OTI patients	3.06	0.73	3.53	0.50	−0.46	<0.001*	0.62
Incorporates BCS into practice	2.80	0.80	3.76	0.43	−0.96	<0.001*	0.68
Non-verbal communication with OTI patients	2.73	0.86	3.93	0.25	−1.20	<0.001*	0.80
Knowledge of AAC	1.43	0.50	3.40	0.49	−1.96	<0.001*	0.71
Need for communicative resources	3.73	0.52	3.90	0.30	−0.16	0.09	0.53
Changes in health status	3.80	0.40	4.00	0.00	−0.20	0.01*	0.40
Perception of effective communication	3.83	0.37	4.00	0.00	−0.16	0.02*	0.37

Note: SD: standard deviation; MD: mean difference/change pre–post values.

*

Significant parameter. Effect size ranged from mild–moderate (|d| > 0.50) to large-high (|d| > 0.80). Pearson's chi-square test.

Description of the level of knowledge in relation to BCS and AAC after CONECTEM training

In the results of the assessment of objective knowledge after the training, all the participants of the training correctly answered more than 75% of the questions posed in two of the three practical cases. Specifically, for Case 1, 90% (n = 27) obtained a high score (above 75% correct answers) while the other 10% (n = 3) had a medium score (50% correct answers). For Case 2, 96.7% (n = 29) had a high score and only 3.3% (n = 1) had a medium score, while for Case 3, 93.4% (n = 28) of the nurses obtained a high score and 6.7% (n = 2) a medium score. Therefore, the results presented indicate that 23.3% (n = 7) of nurses obtained an intermediate level of knowledge in BCS and AAC, while 76.7% (n = 23) obtained a high level of knowledge. Consequently, it can be concluded that all participants who completed the training had acquired a sufficient level of knowledge about BCS and AAC to be able to apply it in clinical practice, as none of the nurses obtained a low level of knowledge.

Degree of satisfaction with the CONECTEM programme

With regard to the satisfaction of nurses with the training received in BCS and AAC (CONECTEM), it is evident that 33.3% (n = 10) of participants evaluated it as good, while 66.7% (n = 29) gave it a rating of very good. The remaining items evaluated in relation to satisfaction (i.e. the materials provided and the method used, the organisation of the course, the information received, the clarity of the concepts, the teacher's response to questions asked by students, and the encouragement of student participation) were also rated as good or very good, with the item on encouraging participation standing out in particular, where 83.3% (n = 25) of nurses rated it as very good.

Discussion

Description of nurses’ perception of knowledge of BCS and AAC

Before the training, the nurses participating in the study reported having little or no knowledge of AAC, and varying levels of knowledge of BCS. While approximately half of the nurses reported having little knowledge of BCS, the other half indicated that they had undergone training in this area during heir undergraduate or postgraduate studies. These results are consistent with previous studies indicating a knowledge gap regarding communication techniques, particularly AAC, among nursing professionals.^30,31 Although a wide range of communication training is available to nurses in the form of courses or books,³² there is currently no compulsory university course or other formal training within the nursing degree programme.³³ Similarly, various authors have conducted face-to-face¹³ or online.³⁰ AAC training courses for ICU nurses with the aim of developing and implementing these techniques in clinical practice. In an online training course conducted by Momennasab et al. (2023) and delivered via video on the WhatsApp platform, nurses’ satisfaction and level of knowledge were assessed in the first phase. In the second phase, the course's effectiveness was evaluated through observation in clinical practice. The value of CONECTEM training lies in its validation and accreditation by a university institution, with specific content blocks as described in this study.

Despite the diversity of perceptions of knowledge about BCS reflected in the results of this study, around 78.3% (n = 94) of nurses reported that they incorporated these communication techniques into their healthcare practice. This suggests that nurses recognise the importance of communication in a person's health and illness process.²⁷ Interpersonal relationships in the therapeutic process are essential to be able to provide quality nursing care to the patient, contemplating the person in a comprehensive way, and placing them at the centre of nursing care.³¹ For this reason, their professionalism makes them try or learn to communicate effectively based on their knowledge and experiences.

In relation to communication with patients on mechanical ventilation, the participants indicated that they used mostly verbal, rather than non-verbal, communication. In fact, surprisingly, approximately 27% (n = 33) of the participants indicated that they never or almost never used non-verbal communication with intubated patients. These data suggest that it is more comfortable for them to communicate verbally with the intubated patient, even though this entails a high rate of ineffective patient-nurse communication and a high degree of frustration.^11,34 In other European countries with cultures different from ours, nurses report more frequent communication with critically ill intubated patients through non-verbal communication, unlike the results of our study. Nurses in Eastern Europe (75–80%) shared the same view as in in our study that effective communication with critically ill patients with verbal or physical limitations is very complicated. Additionally, 32–56% believed that their own social and communication skills hinder the nurse–patient relationship, as they do not have sufficient training.³² Importantly, the nurses included in our study already had previous training in BCS (which are based on empathy, active listening, and use of verbal communication), and perhaps they did not have as much training in non-verbal communication strategies.

In terms of the time and frequency that nurses invested in interacting with the critical patient, most communicated more than five times per shift, but with a maximum duration of 3–5 minutes per interaction. These data coincide with the study by Happ (2014) in which nurses who had not received any training also communicated with an average frequency of 5.5 times per shift for an average duration of 3 minutes, while among those who had completed training in BCS or AAC the frequency of interactions increased to 7.5 times per shift.¹³ It is true that to detect the patient's physical needs, if communication is effective, with 5 minutes we can resolve the patient's requests (for example, if the patient is cold, a blanket can be provided). However, to establish a climate of trust and a therapeutic relationship in which there is space for self-expression and feedback, more time is needed to understand the situation in which the patient finds themselves.^26,33 Effective nurse-critical patient communication requires patience, the appropriate attitude, commitment, and practice.^15,35

In relation to the nurses’ perception of the effectiveness of communication with the critical patient, the results indicate that 78.3% (n = 94) of the nurses perceived that they were communicating effectively, although when communication was not effective, 80% (n = 96) of nurses reported feeling frustrated. The findings are in line with the results of the SPEAKS 2 study, which found that 72% of nurse-critical patient interactions were effective.³⁶ Nurses’ feelings of frustration and helplessness when communication is not effective^37,38 is an obstacle to effective nursing care for the critically ill.¹⁰ As experts have pointed out, ineffective communication leads to a decrease in the quality of care, producing psycho-emotional effects in the patient such as anxiety and the underestimation of pain.^8,39,40

Likewise, most participants (88%) stated that they did not know or knew very little about AAC. The few nurses who used these resources had done so on their own initiative since they had not received any training in AAC. Pioneering studies on communication with critically ill patients describe how nurses relied on previous experience and a trial-and-error approach to communication.^41,42 These studies align with the results of our study, indicating that the most frequently used techniques were writing, using signs/gestures, and lip reading, in descending order of frequency.^43,44 A systematic review of the application of AAC in critically ill patients shows that there are several barriers to their use. Among the most prominent are the lack of training of nurses, the lack of resources, the cognitive and emotional state of the patient, and considering communication to be secondary to other concerns.⁴⁵

Knowledge of nurses pre- and post-CONECTEM training

The results of the quasi experimental study provide evidence of the effectiveness of the training programme in communication techniques for ICU nursing staff, specifically in relation to nurses’ perceptions and levels of knowledge. Improvements were observed in nearly all the evaluated categories, with the sole exception being the need for communication resources, as the demand for such resources by nursing professionals remained high both pre- and post-training. This outcome is probably due to the lack of implementation of AAC in the critical care units of the study area. It is important to note, however, that training requires regular updates and continuous application, as the knowledge acquired may fade over time or its long-term impact may diminish. Consequently, the duration of the training's effect remains uncertain.

The literature reviewed reinforces the growing demand for training of nursing personnel and the implementation of communication resources.⁴⁶ This demand increased during the COVID-19 pandemic, when the need for communication with critically ill patients on mechanical ventilation became evident and aroused a greater interest in AAC in intensive care nurses.²¹ Seeing communication as essential in the care of the critically ill improves the predisposition of nurses in the use of AAC.^15,23

After the training, the perception of the use of verbal and non-verbal communication with the intubated patient improved significantly, and knowledge of low-tech and high-tech AAC increased, as 43% (n = 13) of nurses stated that they would use both low- and high-tech ACC, while 57.6% (n = 17) stated they would use only low-tech ones. In this sense, CONECTEM training facilitates the application of AAC in the clinical practice of ICU nurses. Scientific evidence shows that there are facilitating elements for the application of AAC in clinical practice in ICUs related to training in these communicative techniques. The use of AAC allows us to know how to select each communication strategy according to the needs of the patient,⁴⁷ facilitates effective communication and/or understanding of the message, and improves the satisfaction and self-esteem of the patient and nurses.⁴⁸ Access to resources and devices,⁴⁹ as well as expert practice and advice, also facilitate the use of these techniques.³⁵

When comparing the effectiveness of our training intervention with those proposed by other authors, we can see that an accredited training intervention that is validated by experts improves the knowledge and application of AAC in the clinical practice of ICU nurses,⁵⁰ in addition to increasing their perception of the importance of effective communication and its relationship to patients’ health, since nurses are able to identify patients’ needs (physical support, emotional support, information, and communication with the people around them), reducing the degree of frustration of nurses and improving the care of the critically ill.^4,30,51 Nurses take the initiative in interacting with the patient, favouring communication with the patient and facilitating the predisposition of both to effective communication.^52,53

As noted by experts, it is important to enhance the training of nurses in communication techniques to increase their confidence and their social and communicative skills within the framework of comprehensive care for critical patients.^14,30,54 The interdisciplinary patient-centred vision of nursing care is a quality standard in the development of the nursing profession. However, such training must be formally structured, evaluated by experts, and applicable to the clinical practice of nurses in ICUs.⁵⁰ The availability of both structural and support resources for health institutions is a key factor in the implementation of such training.⁴⁶

For this reason, our results suggest the implementation of formally structured and accredited training by a university institution, based on knowledge, skills, and aptitudes in BCS and AAC to improve communication with the critical patient.

Satisfaction assessment for CONECTEM training

In order for the training to be valued and useful for nursing professionals, it must be practical and easy to incorporate into the nurses’ work activity. The use of workshops and role-playing as a learning method received the highest share of top scores (83.3% scored very well and 16.7% well). These results coincide with Dithole (2017), where 100% (n = 22) of the nurses who underwent training in communication techniques valued the workshops positively, as they helped them to successfully choose a communication strategy for each patient.¹⁵ The rest of the items in relation to satisfaction with the training (case evaluation, clarity in explanations, the teacher's expertise, the information provided, and the general organisation of the course) were rated by the participants in a range between good and very good. Nurses trained in BCS and AAC viewed positively the reinforcement of their knowledge and the opportunity to learn about communication, because it enhanced their approach to critically ill patients.⁵⁵ Additionally, receiving training added value to their professional careers by recognising and enhancing their expertise.

Limitations

The study has several limitations. Firstly, it is a single-centre project, so we must be very cautious when generalising results to other nursing teams in other hospitals or even in other ICUs. Another limitation is that we did not evaluate the adherence of training to clinical practice or the impact of training on nursing care for critically ill patients. A next step would be necessary to replicate the study at other hospitals and carry out a more in-depth analysis of the usefulness of this training and adherence to it in clinical practice in order to assess its effectiveness in communicating with critically ill patients.

Conclusion

The study found that nurses working in the ICU had a limited understanding of AAC, with most reporting that they used BCS when communicating with critically ill patients. However, only half of the nurses surveyed reported being familiar with these strategies. Nevertheless, nurses consistently acknowledged the importance of nurse–patient communication in their clinical practice. In this context, the findings of the present study lend support to the implementation of formally structured and accredited training, such as the CONECTEM programme, delivered by a university institution and focused on developing knowledge, skills, and attitudes in BCS and AAC. This training programme was found to have a significant impact on the participants’ understanding and utilisation of communicative resources, thereby enhancing their perception of the correlation between effective communication and positive patient outcomes. Furthermore, the participants expressed a high level of satisfaction with the training, particularly about the practical methodology employed, such as workshops and role-playing. Importantly, the results emphasise the need to address the current lack of communication training not only within university curricula but also within hospitals and intensive care units. Greater training in communication skills promotes more effective nurse–patient interaction and, consequently, stronger support for critically ill patients. These findings underscore the relevance of integrating communication competencies into ongoing professional development for critical care nurses.

Authors’ contributions

MPA, MPLL, CMA, TLLC: conceptualisation, methods, investigation, funding acquisition. ZAI, MPA: formal analysis, data curation. MER, BGV, DTV: investigation, data curation. MPA, ZAI, CMA: writing (original draft preparation). MPA, MLLC, MPLL: visualisation, MPLL: monitoring. MPA, MLLC, AHB: writing (reviewing and editing). MPA, CMA, MER, AHB: resources. All authors read and approved the final manuscript.

Ethical approval

This study was approved by the Ethics Committee of the Vall D’Hebron University Hospital with reference PR(AG)120/2019. All nurses who completed the training signed an informed consent form and were afforded confidentiality.

Informed consent

Not applicable.

Funding

This research was funded with 3850 euros from the Fundación Enfermería y Sociedad programme (Research Commission of the Official Nursing Association of Barcelona). Registration No: PR-384/2019.

Conflicts of interest

The authors declare that they have no competing interests.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgements

This work is part of a communicative intervention project with critical patients in the ICU of Vall D’Hebron Hospital. We thank the supervisor of the UCI (BG), as well as the person responsible for data collection (ME) for their involvement in the project. We are also grateful for the collaboration of all the ICU nurses who have participated in the study.